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Introduction Cases of neonatal abstinence syndrome (NAS) increased 3-fold in the United States from 2000 to 2009, with some indication that the problem may be worse in rural areas. The purpose of our study was to report the incidence of NAS in a small rural community with a regional referral hospital and describe aspects of these infants’ NICU stay. Methods Using maternal prenatal positive urine drug screens (UDS) as our initial focus, deliveries at 35 weeks or beyond between March 2015 and May 2016 were included. NAS severity score, length of NICU stay, and hospital charges for each infant were obtained from chart review. Results Thirty three of 981 infants developed NAS requiring NICU admission. Most of these were not identified by either a prenatal history or a routine first prenatal visit UDS. For the 7 infants who were identified as at risk by a positive UDS early in pregnancy, the average length of stay in the NICU was 10 days, the average NAS score was 8, and the average NICU charge was $46,000 compared to $3,440 charge for a term normal newborn. Discussion Many studies have shown that neonatal abstinence syndrome is becoming more common, and some suggest that it may be a bigger problem in rural areas. While prenatal UDS may be helpful, many exposed infants will be missed. Even when exposure is proven, without reasonable access to medication assisted treatment during pregnancy, the outcome may still be unfavorable. The precise prevalence and cost in rural hospitals that serve as regional referral centers are needed for adequate health service planning. This planning includes strategies to increase local access to treatment options for pregnant women dependent on opioids.